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Belching in Gastroesophageal Reflux Disease

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Belching in Gastroesophageal Reflux Disease Journal of Clinical Medicine Review Belching in Gastroesophageal Reflux Disease: Literature Review Akinari Sawada 1 , Yasuhiro Fujiwara 1,* and Daniel Sifrim 2 1 Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan; [email protected] 2 Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AJ, UK; [email protected] * Correspondence: [email protected] Received: 4 October 2020; Accepted: 19 October 2020; Published: 20 October 2020 Abstract: Belching is a common phenomenon. However, it becomes bothersome if excessive. Impedance–pH monitoring can classify the belching into two types: gastric belching and supragastric belching (SGB). The former is a physiological mechanism to vent swallowed air from the stomach, whereas the latter is a behavioral disorder. Gastroesophageal reflux disease (GERD) is the most relevant condition in both types of belching. Recent findings have raised awareness that excessive SGB possibly sheds light on the pathogenesis of a part of proton pump inhibitor (PPI) refractoriness in GERD. SGB could cause typical reflux symptoms such as heartburn, regurgitation or chest pain in two ways: SGB-induced gastroesophageal reflux or SGB-induced esophageal distension. In PPI-refractory GERD, it is important to detect hidden SGB as a cause of reflux symptoms since SGB requires psychological treatment instead of high dose PPIs or pain modulators. In the case of PPI-refractory GERD with excessive SGB, recent studies imply that the combination of a psychological approach and conventional treatment can improve treatment outcome. Keywords: gastric belching; supragastric belching; epidemiology; impedance-pH monitoring; gastroesophageal reflux disease; non-erosive reflux disease; reflux hypersensitivity; functional heartburn 1. Introduction Belching is defined as “an audible escape of air from the esophagus or the stomach into the pharynx” [1]. Although everyone belches, it can be bothersome when excessive and/or triggering reflux symptoms. If patients cannot control belching in public, they often feel embarrassed, which profoundly disturbs their social lives. Such patients understandably seek medical care for their belching symptom. On the other hand, some patients predominantly complain of typical reflux symptoms rather than belching, even though excessive belching itself causes reflux symptoms [2–4]. Due to poor response to proton pump inhibitors (PPIs) therapy, those patients are often referred to specialists as PPI-refractory gastroesophageal reflux disease (GERD) [2,4–6]. Recent studies suggest that hidden SGB is a possible cause of PPI refractoriness in a deceptively large proportion of GERD. SGB has to be diagnosed appropriately as it requires dedicated psychological therapy. This literature review summarizes belching with regard to mechanisms, epidemiology, relevant conditions, and treatment, focusing on the association with GERD. 2. Two Types of Belching: Gastric Belching and Supragastric Belching 2.1. Gastric Belching (GB) GB is a physiological mechanism to vent swallowed air from the stomach. Air-induced distension of the proximal stomach triggers transient lower esophageal relaxation (TLESR), which allows the J. Clin. Med. 2020, 9, 3360; doi:10.3390/jcm9103360 www.mdpi.com/journal/jcm J. Clin. Med. 2020, 9, x FOR PEER REVIEW 2 of 14 2. Two Types of Belching: Gastric Belching and Supragastric Belching 2.1. Gastric Belching (GB) J. Clin.GB Med. is2020 a , 9physiological, 3360 mechanism to vent swallowed air from the stomach. Air-induced2 of 14 distension of the proximal stomach triggers transient lower esophageal relaxation (TLESR), which gasallows to bethe released gas to be retrogradely released retrogradely to the pharynx to the (Figurespharynx1 (Figuresand2). TLESR1 and 2). is aTLESR vagal is reflex a vagal via reflex the brainstem,via the brainstem, not a local not reflex a local [7]. reflex In detail, [7]. In the detail, vagal athefferent vagal conveys afferent the conveys stretch ofthe cardiac stretch stomach of cardiac to thestomach brainstem to the via brainstem nodose ganglion via nodo andse solitaryganglion nucleus. and solitary Subsequently, nucleus. vagal Subsequently, efferent projecting vagal efferent to LES fromprojecting the brainstem to LES from releases the brainstem nitric oxide releases and vasoactive nitric oxide intestinal and vasoactive peptide, whichintestinal relaxes peptide, the LES which [8]. Duringrelaxes the TLESR, LES esophageal[8]. During TLESR, shortening esophageal often occurs shortening by much often stronger occurs contraction by much stronger of the longitudinal contraction muscleof the longitudinal than circular muscle muscle. than The circular discordance muscle. of Th thesee discordance two muscle of layers these stretches two muscle myenteric layers stretches neurons tomyenteric release nitric neurons oxide, to release which isnitric possibly oxide, involved which is with possibly the mechanism involved with of TLESR the mechanism [9]. of TLESR [9]. FigureFigure 1.1. Gastric belching andand supragastricsupragastric belchingbelching inin impedance–pHimpedance–pH monitoring.monitoring. Each row inin impedance–pHimpedance–pH tracingstracings measures,measures, from thethe bottom,bottom, gastricgastric pH;pH; esophagealesophageal pH atat 55 cmcm aboveabove thethe lowerlower esophageal sphincter sphincter (LES); (LES); and and impedance impedance at at 3, 3,5, 5,7, 7,9, 9,15, 15, and and 17cm 17cm above above the theLES. LES. In GB In ( GBA), (anA), increase an increase of impedance, of impedance, indicating indicating air from air from the thestomach, stomach, moves moves retrogradely retrogradely from from the thedistal distal to the to theproximal proximal esophagus. esophagus. This This GB GB is isimmediately immediately followed followed by by a aliquid liquid reflux reflux episode episode (i.e., retrograderetrograde B impedanceimpedance decrease).decrease). On On the other hand, SGB ((B) startsstarts withwith antegradeantegrade movementmovement ofof impedanceimpedance increase by sucking or swallowing air from the pharynx; subsequently, such increase returns to baseline increase by sucking or swallowing air from the pharynx; subsequently, such increase returns to retrogradely by abdominal straining. This SGB induces a liquid reflux episode. Apart from the SGB baseline retrogradely by abdominal straining. This SGB induces a liquid reflux episode. Apart from inducing reflux, there are two other patterns of the relationship between SGB and reflux. (C) shows the SGB inducing reflux, there are two other patterns of the relationship between SGB and reflux. (C) that several SGBs (blue arrowheads) occur during liquid reflux in which an uncomfortable sensation by shows that several SGBs (blue arrowheads) occur during liquid reflux in which an uncomfortable reflux might lead a patient to perform SGBs. (D) shows SGBs (blue arrowheads) without reflux. In this sensation by reflux might lead a patient to perform SGBs. (D) shows SGBs (blue arrowheads) without case, a patient constantly marked heartburn immediately after SGBs, which suggests the SGBs caused reflux. In this case, a patient constantly marked heartburn immediately after SGBs, which suggests reflux symptoms by esophageal distension. Black arrows indicate the movement of air, whereas red the SGBs caused reflux symptoms by esophageal distension. Black arrows indicate the movement of arrows indicate liquid reflux. air, whereas red arrows indicate liquid reflux. J. Clin. Med. 2020, 9, 3360 3 of 14 J. Clin. Med. 2020, 9, x FOR PEER REVIEW 3 of 14 Figure 2. GastricFigure 2. belching Gastric belching and supragastric and supragas belchingtric belching in HRM in HRM combined combined with with impedance. impedance. These These pictures illustrate GBpictures (A) illustrate and SGB GB ((BA)) inand simultaneous SGB (B) in simultaneous recording recording of impedance of impedance and and HRM. HRM. (A (A) A) AGB GB occurs occurs with liquid reflux during TLESR. GB can be recognized as a common cavity in HRM. The air with liquidevacuates reflux from during the stomach TLESR. to the GB pharynx can be through recognized the relaxed as UES. a common (B) In SGB, cavitythe contraction in HRM. of The air evacuatesthe from diaphragm the stomach generates to negative the pharynx pressure through in the esophagus. the relaxed UES UES.relaxation (B) Inlets SGB, air into the the contraction of the diaphragmesophagus generatesfollowed by expelling negative the pressure air by abdomina in thel straining. esophagus. No peristalsis UESrelaxation is involved with lets the air into the esophagusair followed movement by in SGB. expelling Black arrows the air indicate by abdominal the movement straining. of air whereas No peristalsisred arrows indicate is involved liquid with the reflux. HRM; high resolution manometry, TLESR; transient lower esophageal sphincter relaxation, air movementUES; upper in SGB. esophageal Black arrowssphincter. indicate the movement of air whereas red arrows indicate liquid reflux. HRM; high resolution manometry, TLESR; transient lower esophageal sphincter relaxation, UES; upper2.2. esophageal Supragastric sphincter. Belching (SGB) SGB is a behavioral disorder where a patient sucks or swallows air from the mouth into the 2.2. Supragastricesophagus, Belching immediately (SGB) followed by expelling it through the pharynx (Figures 1 and 2). Regarding SGB isits physiological
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